Transcription of Medical Baseline Allowance Application For …
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Medical Baseline Allowance Application For …
Medical Baseline Allowance Application For Medical Baseline enrollment and Re Certification PLANNED OUTAGE CONTACT PREFERENCE Call me by phone Contact me by TDD/TTY at phone Send me a text message at phone Send me an email at UNPLANNED OUTAGE CONTACT PREFERENCE Call me by phone Contact me by TDD/TTY at phone Send me a text message at phone Send me an email at CUSTOMER NAME (as it appears on PG&E bill) Medical Baseline RESIDENT S NAME (if different) SERVICE ADDRESS APT # CITY STATE ZIP CODE CUSTOMER MAILING ADDRESS (if different) APT # CITY STATE ZIP CODE HOME PHONE # WORK PHONE # STEP 1 Account and Customer Information (please print) PG&E CUSTOMER ACCOUNT NO NAME OF MOBILE HOME OR APARTMENT COMPLEX COMPLEX ADDRESS COMPLEX MANAGER S NAME COMPLEX PHONE # TENANT S NAME TENANT S PHONE # STEP 2 For customers billed by someone other than PG&E Please check your PREFERRED method(s) for being contacted below and provide all of the relevant information next to your selection.
Medical Baseline Allowance Application For Medical Baseline Enrollment and ReCertification PLANNED OUTAGE CONTACT PREFERENCE Call me by phone
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